Preparing for Payer
Audits After COVID-19
As the country starts to open up at the end of the COVID-19 pandemic, payers are using the down time they experienced to increase auditing of services
claimed during the Public Health Emergency (PHE). Some payers have specifically increased Telehealth scrutiny and are providing training to their internal investigative units to detect fraud, waste, and abuse.
The PHE declaration made it imperative to provide immediate services remotely with little or no training. This was done to assist critical care facilities in coping with the crisis and ensure social distancing practices and patient safety.
The lack of technology and unfamiliarity with tele-health coding, billing services and e-Health software vendor platforms may have contributed to healthcare providers not having time to evaluate their tele-health delivery partner.
To protect themselves when the PHE declaration is lifted, providers should take
time to assess their tele-health delivery partner by examining the following:
Future business partnership
Billing & Coding
In addition to inexperience in providing tele-health services and e-Health services, many providers, and even Industry “experts” – coders and billers
- also had a lack of knowledge of coding and billing for these services which increased their risk for improper coding and billing.
The regulatory environment was rapidly changing as the pandemic continued,
Temporary expansions of tele-health coverage
Coding and billing additions
Place of service changes
Timeframe allowances for these expansions
The challenge of keeping up with these various payers, including CMS, may have contributed to mistakes in coding and billing. It is believed that some leniency will be extended to healthcare providers that have inadvertently committed these kinds of errors, basically a good faith assumption.
To counter deliberate violations which constitute fraud, payers have increased their audit focus looking for specific incidents. Since payers did not uniformly implement the same guidance for their claim forms, providers will need to
track the following information to be included on the claim forms:
1. Regulatory expansions
2. Point of Service
Note: On April 1, 2020, CMS suspended most fee-for-service (FFS) medical reviews during the PHE.
According to CMS’s (FAQs), there will be no additional documentation requests, reviews that are in process will be suspended and any claims will be released and paid. However, medical reviews may still occur if there is an indication of potential fraud.
Private payers expanded telehealth coverage, but with limited timeframes. This will require provider internal audit teams to adjust the annual audit plan based upon risks.
Tele-health auditing may not have been a priority risk within the 2020 plan,
but it is now.
Special Investigative Units (SIU) are increasing the audits of telehealth and
eHealth services during the PHE break in non-emergent procedures and
in-person office visits.
Per HMS Healthcare article “Preventing Healthcare Fraud during Coronavirus”,
some insight is provided into payers' perspectives and fraud audit plan activities.
The “low tide phenomenon”
This will be a focus strategy and is easily triggered as fraudsters will not be
able to drop their claims rate which will trigger an audit.
They will identify shuttered businesses and ensure a business has not gone out of business.
Claims Detection Capability
Increase claims detection capability to identify services provided to patients never seen by the provider on previous claims or for a new ICD-10 code. These may result in pre- and post-payment reviews.
Cost Sharing Oversight Payers
Payers are developing processes to better understand, from a legal perspective, when the cost-sharing amounts are allowed to be waived during the PHE and not subject to the Anti-Kickback Statute.
SIUs are training staff to conduct post-payment audits of telehealth and eHealth payments to better understand the compliant coding and billing requirements prior to the PHE and during the
PHE. This is occurring across all payers.
Put a process in place to respond to audits in an efficient and timely manner. Administratively; this would be substantially similar to RAC requests.
Identify individuals to lead your audit responses.
Consider conducting an external audit of your tele-health and eHealth claims for coding and billing compliance.
Conduct a risk assessment, when the PHE is over, to review the new treatment service methods to be implemented to ensure HIPAA compliance.
NOTE: When the PHE is lifted, full HIPAA security compliance will be in full force once again and any agreements with business associates will also need to meet the HIPAA security standards.
Guidelines for preserving PPEs can be found at:
CDC Guidelines for Opening Up America Again are found at: